Office Hours

In order to provide you the best possible wellness care, please complete this form

Patient Data

First Name *

Last Name *

Date

Email (Your email will NOT be shared with any third parties, and is used for occasional office announcements and promotions.) *

Mailing Address

Address

City

State

Zip

Telephone (Home or Cell)

Referred By

Age

Birth Date

Social Security #

Number of Children

Occupation

Employer

Emergency Contact

Phone

Current Complaints

Nature of Injury

Automobile*

Work

Other

Please Describe

Date of Injury

Date Symptons Appeared

Have you ever had same condition?

No

Yes

Have you ever been under chiropractic care?

No

Yes

If yes, please describe

Insurance Information (please bring a copy of your insurance card to the office)

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Medical History

Have you been treated for any conditions in the last year?

No

Yes

If yes, please describe

What medications are you taking and for what conditions (Please list dosage and amounts, etc).

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Habits

Coffee

None

Light

Moderate

Heavy

Exercise

None

Light

Moderate

Heavy

Water

None

Light

Moderate

Heavy

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Sign-up using the form or call us at 845-620-0939 to take advantage of this exclusive offer.

Name: *

Email: *

Phone: *

Office Hours

Day

Morning

Afternoon

Monday

Closed

Closed

Tuesday

9 - 12:30

3 - 7

Wednesday

Closed

Closed

Thursday

9 - 12

Closed

Friday

Closed

3 - 7

Saturday

9 - 1

Closed

Sunday

Closed

Closed

Services

We strive to provide complete care for our patients. Learn more about all the services we provide.